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Providers

Provider Forms

Provider Forms

For your convenience, we've provided a list of common forms that you can download any time.

  • Authorization Form - Medications Requiring Prior Authorization
  • Authorization form - General/Medical/Surgical
  • Authorization Form - Mental/Behavioral Health
  • Designation as Secondary Care Physician for a Health Plan Patient
  • Eligibility Statement Request Form
  • Eligibility/Benefits/Claim Status Request Form
  • Formulary Addition Request Form
  • Medicare Part D Coverage Determination Request Form
  • MyBenefits Web Provider Module Sign On Request Form
  • Provider Appeal Request Form
  • Provider Data Sheet
  • Provider Data Update Form
  • Provider Status Change Form
  • Shared Decision Making Referral - Fax Form
  • Shared Decision Making - RX/Checklist Pad
  • Specialty Drug Request Form 
  • SWHP S&W System Providers Technical Assessment Form
  • SWHP Non-S&W System Providers Technical Assessment Form
  • Texas Standardized Credentialing Application